Clinical Case Summary

Background: Pancreatic Adenocarcinoma (PA) represents an aggressive disease affected by very poor prognosis worldwide. In the early phases, PA remains asymptomatic favoring delayed diagnosis and affecting the disease prognosis. Recently, Acute Pancreatitis (AP) has been described by some anecdotical cases as a potential early manifestation of PA, in particular if case of pancreatic head development.
Case presentation: An 80-year-old female patient affected by diabetes mellitus type 2 complaining of acute epigastric pain was admitted to the emergency room receiving an AP diagnosis. After 2 days she was hospitalized at Gastroenterology Department to receive medical treatment. On admission, the patient presented hyper-neutrophilia, elevated levels of pancreatic enzymes, cholestasis indexes, and phlogosis markers. Abdominal ultrasound revealed a hypoechoic nodular lesion of 40 mm located at the pancreas body, associated with ectasia of the upstream Wirsung duct. The contrast enhancement US (CEUS), evidenced a hypoenhancement pattern in the arterial phase suggesting the need for a second-level imaging examination. The abdominal CT scan revealed the lesion ventral to the splenic-portal confluence without signs of vascular infiltration, presenting a late contrast enhancement suggestive of a hetero-primitive lesion of the pancreatic body. Echo-endoscopy-guided sampling confirmed the adenocarcinoma diagnosis. After this, the patient received a distal pancreatectomy to achieve surgical radicality. No progression of disease was observed after surgery, and she is currently on stable oncological follow-up.
Conclusion: Even when the neoplasm is not located in the head of the organ, AP has herein been reported as a rare exordial manifestation of PA whose onset can help clinicians to achieve early diagnosis of this aggressive tumor.

References

1. Saluja A, Maitra A. Pancreatitis and Pancreatic Cancer. Gastroenterology. 2019 May;156(7):1937-1940. doi: 10.1053/j.gastro.2019.03.050. Epub 2019 Mar 30. PMID: 30940522.
2. Bezuidenhout AF, Wei PK, Burstein D, Brook A, Brook OR, Freedman SD, Tsai LL. Unexplained Acute Distal Pancreatitis: Association With Subsequent Diagnosis of Pancreatic Cancer. AJR Am J Roentgenol. 2023 Aug;221(2):196-205. doi: 10.2214/AJR.23.28999. Epub 2023 Mar 22. PMID: 36946899.
3. Walling A, Freelove R. Pancreatitis and Pancreatic Cancer. Prim Care. 2017 Dec;44(4):609-620. doi: 10.1016/j.pop.2017.07.004. Epub 2017 Oct 5. PMID: 29132523.

Introduction

Helicobacter pylori is a common cause of peptic ulcers and gastritis. Standard triple therapy includes a PPI with amoxicillin and either clarithromycin or levofloxacin. Rising antibiotic resistance has reduced its effectiveness. Sequential therapy offers a phased alternative with better outcomes in resistant cases.

Aims & Methods

To evaluate and compare the efficacy of clarithromycin and levofloxacin-based triple and sequential therapies for Helicobacter pylori (H. pylori) eradication in a resource-limited setting, in the context of emerging antibiotic resistance.
A prospective, randomized study was conducted at a tertiary care center from January 1, 2022, to January 1, 2025. A total of 300 treatment-naïve patients aged 18–60 years, diagnosed with H. pylori infection through stool antigen, urea breath test, or histology, were included. Patients with prior eradication therapy or recent antibiotic use were excluded. Participants were randomized into four equal groups (n=75 each):

• Clarithromycin-based triple therapy (amoxicillin, clarithromycin, PPI)
• Levofloxacin-based triple therapy (amoxicillin, levofloxacin, PPI)
• Clarithromycin-based sequential therapy (amoxicillin + PPI for 5 days, followed by clarithromycin + tinidazole + PPI for 5 days)
• Levofloxacin-based sequential therapy (amoxicillin + PPI for 5 days, followed by levofloxacin + tinidazole + PPI for 5 days) Therapeutic response was assessed post-treatment for eradication.
  

Results

Out of 300 patients (180 males, 120 females), eradication was achieved in:

• 48/75 (64%) in clarithromycin-based triple therapy
• 53/75 (70.7%) in levofloxacin-based triple therapy
• 51/75 (68%) in clarithromycin-based sequential therapy
• 61/75 (81.3%) in levofloxacin-based sequential therapy

All patients completed therapy without notable adverse events or compliance issues. Lower eradication rates in clarithromycin-based regimens suggest rising resistance.

Conclusion

Levofloxacin-based sequential therapy demonstrated the highest eradication rate, highlighting its potential as a preferred regimen in settings with rising clarithromycin resistance. Clarithromycin-based treatments showed suboptimal outcomes, emphasizing the need for region-specific antibiotic stewardship and resistance surveillance.

References

1. Kim JS, Kim BW, Hong SJ, Kim JI, Shim KN, Kim JH, Baik GH, Kim SW, Song HJ, Kim JH. Sequential Therapy versus Triple Therapy for the First Line Treatment of Helicobacter pylori in Korea: A Nationwide Randomized Trial. Gut Liver. 2016 Jul 15;10(4):556-61. doi: 10.5009/gnl15470. PMID: 27114421; PMCID: PMC4933415.
2. Chang, J.Y., Shim, KN., Tae, C.H. et al. Triple therapy versus sequential therapy for the first-line Helicobacter pylori eradication. BMC Gastroenterol 17, 16 (2017). https://doi.org/10.1186/s12876-017-0579-8

Clinical Case Summary

Introduction: Von Hippel-Lindau (VHL) syndrome is a rare hereditary neurocutaneous disorder distinguished by its propensity for the development of both benign and malignant tumors such as cerebellar hemangioblastomas, retinal angiomas, clear cell renal carcinomas, pancreatic neuroendocrine tumors, and others. Additionally, multiple pancreatic, renal, and urogenital cysts may also develop, potentially giving rise to localized symptoms and the risk of malignant transformations (1).
Case report: This case study centers on a 54-year-old male patient who was flagged for potential tumorous lesions in both kidneys upon undergoing a comprehensive health assessment. Following a multi-sliced computed tomography (MSCT)-guided biopsy, the presence of clear cell renal carcinoma was bilaterally confirmed. An abdominal MSCT delineated an enlarged pancreas featuring multiple cystic formations. Then, an Endoscopic Ultrasound (EUS) examination detailed the presence of multiple cysts in the pancreatic region, forming conglomerates with a collective dimension of up to 80 mm. Following an EUS-FNA (fine needle aspiration) procedure, cuboidal epithelium within the cyst was identified, and a biochemical analysis revealed normal levels of CEA, amylase, and glucose. The combination of these findings, along with the patient's medical history, raised suspicions of serous cystadenoma and prompted consideration of VHL syndrome. Finally, a heterozygous missense variant in the VHL gene was detected by sequencing genes included in the clinical exome panel.
Conclusion: Distinguishing cystic pancreatic lesions, which can give rise to endocrine and/or exocrine insufficiency or be asymptomatic, from potentially malignant lesions is of paramount importance. Therefore, diligent tumor surveillance associated with VHL syndrome is crucial for timely detection and treatment.

References

1. van Asselt SJ, de Vries EG, van Dullemen HM, Brouwers AH, Walenkamp AM, Giles RH, Links TP. Pancreatic cyst development: insights from von Hippel-Lindau disease. Cilia. 2013 Feb 5;2(1):3.

Introduction

EUS-guided Gallbladder Drainage (EUS-GBD) with Lumen Apposing Metal Stent (LAMS) is a standard treatment for management of acute cholecystitis (AC) in unfit-for-surgery patients. Gallbladder Perforation is standardly considered as a contraindication to EUS-GBD.

Aims & Methods

This series aims at exploring outcomes of EUS-GBD in patients with AC and contained perforation (cp-AC).
All consecutive patients undergoing EUS-GBD in a single tertiary institution between 2020 and 2024 were enrolled in a prospective registry (PROTECT, ClinicalTrials.gov NCT04813055). Patients with cp-AC were included in this series, when presenting gallbladder wall rupture with adjacent encapsulated fluid collections. Baseline demographics and technical details were registered together with Technical success, Clinical success, Adverse Events (AEs), Recurrence and Survival evaluated every 60 days.

Results

From a prospective cohort of 48 EUS-GBD, 19 patients presented with cp-AC (median age 71 [62-78], male 42.1%, Charlson Comorbidity Index of 8 [7-9.8]). Acute cholecystitis was iatrogenic in 79% of these cases (ERCP with metal stenting in 14 and TACE in 1). Reason to avoid surgery was underlying malignancy in 89.5% and comorbidities in 15.8%. Amongst underlying malignancies, the most frequent one was Pancreatic Adenocarcinoma.
Ascites was present in 26.3% of cases. All procedures were performed transduodenally, with an operative luminal space of 31 [25 – 36] mm and a median tract thickness of 6 [5-8] mm.
A 10 mm Hot Axios LAMS was used in 95% of cases, and the release was free-hand in 89% and over-the-wire after former distention in 11% of cases. Antibiotic prophylaxis and coaxial double-pigtail plastic stents were adopted in 95% of cases.
Technical success was 100%. Clinical success was 94.7%, with a statistically significant 7-days reduction of white blood cells (p=0.0017 ) and C Reactive Protein (p=0.0067) .
AEs were registered in 21% of cases, severe/fatal in 11%.
Of note, 2 AEs (1 fatal) were related to additional attempts of draining liver abscesses adjacent to the GBD.
Five patients (27%) underwent additional endoscopic procedures for peroral cholecystoscopy, GBD clearance and LAMS removal, while 2 (11%) patients experienced uneventful LAMS migration.
Median hospital stay was 8 [6-13] days and median time to chemotherapy was 26 [19-56] days for those who were candidate to oncological treatment (N=10).
After a median follow-up of 254 [56-454] days, no AC recurrence was registered.

Conclusion

In the context of AC, contained perforation with adjacent collections does not seem to represent a contraindication to EUS-GBD with LAMS, despite the additional complexity related to a thicker interluminal distance. Management of large adjacent abscesses should involve multidisciplinary management and might require percutaneous drainage.

Introduction

Patients with Hypermobile Ehlers Danlos Syndrome (hEDS) have a high prevalence of Disorders of Gut-Brain Interaction (DGBI) and pose complex nutritional challenges in gastroenterology clinic. Despite this, little is known regarding nutrient intake and adequacy in hEDS.

Aims & Methods

Our aim was to assess nutrient intake and adequacy of patients with hEDS, as well as to determine which factors, including co-existent DGBI, are associated with poor intake. We conducted a cross sectional survey of patients with hEDS from two tertiary neurogastroenterology clinics as well as the Ehlers-Danlos Support UK. Inclusion criteria were adults with hEDS, exclusion criteria were those currently or previously using artificial nutrition. Patients completed the validated semi-quantitative Scottish Collaboration Group Food Frequency Questionnaire (FFQ) alongside questionnaires characterising: demographics, DGBIs (Rome IV), gastrointestinal, mood, somatic and autonomic symptoms, past history of eating disorders and screen for Avoidant Restrictive Food Intake Disorder (ARFID) using the Nine Item Avoidant-Restrictive Scale (NIAS). Nutrient intake was calculated from the FFQ and nutrient adequacy was calculated by comparison with UK daily reference values (DRVs) for age and sex. Unpaired t-tests were performed to compare nutrient intakes among patients with and without comorbidities, including the most common DGBIs.

Results

425 participants were included in the final analysis (mean: 41 years, 96% female). Only 48.5% reported BMI in the normal range, whereas 5.2% were underweight (BMI <18.5 kg/m²)and46.4% were overweight/obese (BMI >25 kg/m²). Only one third met their estimated average requirements (EAR) for energy (kcal/d). The majority met their reference nutrient intake (RNI) for protein (87.3%) and fat (72.5%), in contrast to only 21.2% for carbohydrate. Fibre intakes were very low (AOAC mean 23.7g/day (SD: 12.7) with only 24.7% meeting the RNI of 30 g/d. More than 58% of participants met/exceeded their DRV for micronutrients (zinc, magnesium, copper, manganese and selenium) and >95% for vitamins. Patients with functional nausea (n=157) were less likely to meet their protein requirements compared to those without (82.2% vs. 90.3%, p=0.015) and also had lower intakes for sodium (p=0.02), magnesium (p=0.02), calcium (p=0.01), zinc (p=0.002), selenium (p=0.03), folic acid (p=0.02) and vitamin C (p=0.05). Patients with previous eating disorders were less likely to meet nutrient requirements for thiamine (p=0.01) and vitamin B12 (p=0.04). Patients with ARFID (n=110) were less likely to meet requirements for all nutrients (except fat, calcium, vitamin D, vitamin B12) compared to patients without.

Conclusion

Patients with hEDS are rarely underweight and tend to consume high protein, high fat diets that are low in fibre. Functional nausea is the single most important DGBI impacting nutrient intake, as well as previous eating disorders and disordered eating (ARFID). These factors should be considered by clinicians and dietitians when assessing nutrient intake in this complex patient group.

Disclosure

RT, AF and QA have received a grant from EDS-UK to conduct this study. AF undergoes consulting work for Abbvie.
KW has received research funding from Almond Board of California, Danone, International Nut & Dried Fruit Council, and has a patent for volatile organic compounds in the detection and management of IBS.
QA undergoes consulting work for Takeda Pharmacueticals, and Classado Biosciences Ltd.